Browsing by Author "Kuhn, Louise"

Now showing 1 - 8 of 8
  • Thumbnail Image
    Item
    Open Access
    Beyond informed choice: infant feeding dilemmas for women in low-resource communities of high HIV prevalence
    (2002) Kuhn, Louise
    Short regimens of anti-retroviral drugs can significantly reduce the transmission of HIV from mother to child which occurs around the time of delivery, but these drugs do not significantly reduce HIV transmission through breast-feeding. In order to prevent transmission, some have called for the provision of milk formula for HIV-positive women. However, linking milk formula, which is of questionable safety, with anti-retroviral drugs, which are of known benefit, may be dangerous. It may also delay implementation of programmes which provide wider access to anti-retroviral drugs, as well as making access to these drugs contingent (implicitly or explicitly) on willingness to use formula. Implementing international guidelines which support giving HIV-positive women an informed choice between infant feeding alternatives is difficult in practice. The focus on a dichotomised choice has the effect of neglecting to make each choice safer. New findings suggest that the magnitude of HIV transmission associated with breast-feeding can be substantially reduced with optimal breast-feeding practices, including those which maintain the exclusivity of breast-feeding and prevent the development of breast problems. These new findings have created greater awareness of the quality of breast-feeding and have drawn attention to serious deficiencies in the counseling services which assist women regarding lactation issues within maternal and child health services in general, and within programmes aimed at the prevention of mother-to-child HIV transmission in particular. Even if access to anti-retroviral drugs can be improved, training and motivation of counsellors will remain a cornerstone of programmes which are effective in preventing transmission of HIV to children.
  • Thumbnail Image
    Item
    Open Access
    The costs of reducing loss to follow-up in South African cervical cancer screening
    (BioMed Central Ltd, 2005) Goldhaber-Fiebert, Jeremy; Denny, Lynette; De Souza, Michelle; Wright, Thomas; Kuhn, Louise; Goldie, Sue
    BACKGROUND:This study was designed to quantify the resources used in reestablishing contact with women who missed their scheduled cervical cancer screening visits and to assess the success of this effort in reducing loss to follow-up in a developing country setting. METHODS: Women were enrolled in this Cape Town, South Africa-based screening study between 2000 and 2003, and all had scheduled follow-up visits in 2003. Community health worker (CHW) time, vehicle use, maintenance, and depreciation were estimated from weekly logs and cost accounting systems. The percentage of women who attended their scheduled visit, those who attended after CHW contact(s), and those who never returned despite attempted contact(s) were determined. The number of CHW visits per woman was also estimated. RESULTS: 3,711 visits were scheduled in 2003. Of these, 2,321 (62.5%) occurred without CHW contact, 918 (24.8%) occurred after contact(s), and 472 (12.7%) did not occur despite contact(s). Loss to follow-up was reduced from 21% to 6%, 39% to 10%, and 50% to 24% for 6, 12, and 24-month visits. CHWs attempted 3,200 contacts in 530 trips. On average, 3 CHWs attempted to contact 6 participants over each 111 minute trip. The per-person cost (2003 Rand) for these activities was 12.75, 24.92, and 40.50 for 6, 12, and 24-month visits. CONCLUSION: CHW contact with women who missed scheduled visits increased their return rate. Cost-effectiveness analyses aimed at policy decisions about cervical cancer screening in developing countries should incorporate these findings.
  • Thumbnail Image
    Item
    Open Access
    Distribution of high-risk human papillomavirus genotypes among HIV-negative women with and without cervical intraepithelial neoplasia in South Africa
    (Public Library of Science, 2012) McDonald, Alicia C; Denny, Lynette; Wang, Chunhui; Tsai, Wei-Yann; Jr, Thomas C Wright; Kuhn, Louise
    Objective Large studies describing the profile of high-risk Human papillomavirus (hrHPV) genotypes among women in sub-Saharan Africa are lacking. Here we describe the prevalence and distribution of hrHPV genotypes among HIV-negative women in South Africa, with and without cervical intraepithelial neoplasia (CIN). METHODS: We report data on 8,050 HIV-negative women, aged 17-65 years, recruited into three sequential studies undertaken in Cape Town, South Africa. Women had no history of previous cervical cancer screening. Cervical samples were tested for hrHPV DNA using the Hybrid Capture 2 (HC2) assay and all positive samples were genotyped using a PCR-based assay (Line Blot). Women underwent colposcopy and biopsy/endocervical curettage to determine CIN status. The prevalence and distribution of specific hrHPV genotypes were examined by age and CIN status. RESULTS: Overall, 20.7% (95% CI, 19.9-21.6%) of women were hrHPV-positive by HC2, with women with CIN having the highest rates of positivity. Prevalence decreased with increasing age among women without CIN; but, a bimodal age curve was observed among women with CIN. HPV 16 and 35 were the most common hrHPV genotypes in all age and CIN groups. HPV 45 became more frequent among older women with CIN grade 2 or 3 (CIN2,3). Younger women (17-29 years) had more multiple hrHPV genotypes overall and in each cervical disease group than older women (40-65 years). CONCLUSION: HPV 16, 35, and 45 were the leading contributors to CIN 2,3. The current HPV vaccines could significantly reduce HPV-related cervical disease; however, next generation vaccines that include HPV 35 and 45 would further reduce cervical disease in this population.
  • Thumbnail Image
    Item
    Open Access
    Program spending to increase adherence: South African cervical cancer screening
    (Public Library of Science, 2009) Goldhaber-Fiebert, Jeremy D; Denny, Lynette A; De Souza, Michelle; Kuhn, Louise; Goldie, Sue J
    Background: Adherence is crucial for public health program effectiveness, though the benefits of increasing adherence must ultimately be weighed against the associated costs. We sought to determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments in Cape Town, South Africa. M ethodology/Principal Findings: We conducted an observational study of 5,258 CHW home visits made in 2003-4 as part of a community-based screening program. We estimated the functional relationship between spending on these visits and increased appointment attendance (adherence). Increased adherence was noted after each subsequent CHW visit. The costs of making the CHW visits was based on resource use including both personnel time and vehicle-related expenses valued in 2004 Rand. The CHW program cost R194,018, with 1,576 additional appointments attended. Adherence increased from 74% to 90%; 55% to 87%; 48% to 77%; and 56% to 80% for 6-, 12-, 24-, and 36-month appointments. Average per-woman costs increased by R14-R47. The majority of this increase occurred with the first 2 CHW visits (90%, 83%, 74%, and 77%; additional cost: R12-R26). Conclusions/Significance: We found that study data can be used for program planning, identifying spending levels that achieve adherence targets given budgetary constraints. The results, derived from a single disease program, are retrospective, and should be prospectively replicated.
  • Thumbnail Image
    Item
    Open Access
    Reduced acquisition and reactivation of human papillomavirus infections among older women treated with cryotherapy: results from a randomized trial in South Africa
    (BioMed Central Ltd, 2010) Taylor, Sylvia; Wang, Chunhui; Wright, Thomas; Denny, Lynette; Tsai, Wei-Yann; Kuhn, Louise
    BACKGROUND:Treatment of women for high-grade cervical cancer precursors frequently results in clearance of the associated high-risk human papillomavirus (hrHPV) infection but the role of treatment among women without hrHPV is unknown. We investigated whether cervical cryotherapy reduces newly detected hrHPV infections among HIV-positive and HIV-negative women who were hrHPV negative when treated. METHODS: The impact of cryotherapy on newly detected hrHPV infections was examined among 612 women of known HIV serostatus, aged 35 to 65 years, who were negative for hrHPV DNA, and randomized to either undergo cryotherapy (n = 309) or not (n = 303). All women underwent repeat hrHPV DNA testing 6, 12, 24, and 36 months later. RESULTS: Among 540 HIV-negative women, cryotherapy was associated with a significant reduction in newly detected hrHPV infections. Women in the cryotherapy group were 55% less likely to have newly detected hrHPV than women in the control group (95% CI 0.28 to 0.71). This association was independent of the influence of changes in sexual behaviors following therapy (adjusted hazards ratio (HR) = 0.49, 95% CI 0.29 to 0.81). Among 72 HIV-positive women, similar reductions were not observed (HR = 1.10, 95% CI 0.53 to 2.29). CONCLUSIONS: Cervical cryotherapy significantly reduced newly detected hrHPV infections among HIV-negative, but not HIV-positive women. These results raise intriguing questions about immunological responses and biological mechanisms underlying the apparent prophylactic benefits of cryotherapy.
  • Thumbnail Image
    Item
    Open Access
    Sex differences in responses to antiretroviral treatment in South African HIV-infected children on ritonavir-boosted lopinavir- and nevirapine-based treatment
    (2014-02-12) Shiau, Stephanie; Kuhn, Louise; Strehlau, Renate; Martens, Leigh; McIlleron, Helen; Meredith, Sandra; Wiesner, Lubbe; Coovadia, Ashraf; Abrams, Elaine J; Arpadi, Stephen M
    Abstract Background While studies of HIV-infected adults on antiretroviral treatment (ART) report no sex differences in immune recovery and virologic response but more ART-associated complications in women, sex differences in disease progression and response to ART among children have not been well assessed. The objective of this study was to evaluate for sex differences in response to ART in South African HIV-infected children who were randomized to continue ritonavir-boosted lopinavir (LPV/r)-based ART or switch to nevirapine-based ART. Methods ART outcomes in HIV-infected boys and girls in Johannesburg, South Africa from 2005–2010 were compared. Children initiated ritonavir-boosted lopinavir (LPV/r)-based ART before 24 months of age and were randomized to remain on LPV/r or switch to nevirapine-based ART after achieving viral suppression. Children were followed for 76 weeks post-randomization and then long-term follow up continued for a minimum of 99 weeks and maximum of 245 weeks after randomization. Viral load, CD4 count, lipids, anthropometrics, drug concentrations, and adherence were measured at regular intervals. Outcomes were compared between sexes within treatment strata. Results A total of 323 children (median age 8.8 months, IQR 5.1-13.5), including 168 boys and 155 girls, initiated LPV/r-based ART and 195 children were randomized. No sex differences in risk of virological failure (confirmed viral load >1000 copies/mL) by 156 weeks post-randomization were observed within either treatment group. Girls switched to nevirapine had more robust CD4 count improvement relative to boys in this group through 112 weeks post-randomization. In addition, girls remaining on LPV/r had higher plasma concentrations of ritonavir than boys during post-randomization visits. After a mean of 3.4 years post-randomization, girls remaining on LPV/r also had a higher total cholesterol:HDL ratio and lower mean HDL than boys on LPV/r. Conclusions Sex differences are noted in treated HIV-infected children even at a young age, and appear to depend on treatment regimen. Future studies are warranted to determine biological mechanisms and clinical significance of these differences. Trial registration ClinicalTrials.gov Identifier: NCT00117728
  • Thumbnail Image
    Item
    Open Access
    Utilisation and outcomes of cervical cancer prevention services among HIV-infected women in Cape Town
    (2010) Batra, Priya; Kuhn, Louise; Denny, Lynette
    Objective. An audit of outcomes of cervical cancer screening and prevention services for HIV-positive women in Cape Town, South Africa. Design. Retrospective review of clinic registers, patient records and pathology databases at three HIV primary health clinics and a tertiary colposcopy referral centre. Subjects. Women recently diagnosed with HIV at three primary health clinics between 2006 and 2008 (N=2 240); new patients seen for colposcopy at a tertiary referral centre between 2006 and 2009 (N=2 031). Outcome measures. The proportion of women undergoing cervical cancer screening after HIV diagnosis at primary health clinics, demographic characteristics of women referred for colposcopy at a tertiary centre, and outcomes of therapy for precancerous lesions of the cervix. Results. The proportion of women undergoing at least one Pap smear at HIV primary health clinics after HIV diagnosis was low (13.1%). Women referred for colposcopy tended to be HIV-positive and over the age of 30 years, and in most (70.2%) cytological examination revealed high-grade cervical dysplasia. HIV-positive women treated with excision for precancerous lesions of the cervix were significantly more likely than their HIV-negative counterparts to undergo incomplete excision, experience persistent cervical disease after treatment, and be lost to follow-up. Conclusion. Cervical cancer screening efforts must be scaled up for women with HIV. Treatment and surveillance guidelines for cervical intraepithelial neoplasia in HIV-positive women may need to be revised and new interventions developed to reduce incomplete treatment and patient default.
  • Thumbnail Image
    Item
    Open Access
    Why growth monitoring fails : an exploratory study of child malnutrition intervention in a rural African area
    (1991) Kuhn, Louise; Levett, Ann
    This study is an exploratory one of growth monitoring in a rural African village, Thornhill. Growth monitoring is a primary health care approach to prevent child malnutrition in under-developed areas promoted by a variety of development agencies, particularly UNICEF, as a part of the "child survival revolution." It involves weighing children regularly and plotting their weights on a growth chart retained by the child's mother. Growth charts provide a visual display of a child's growth to allow health workers and mothers to identify early signs of growth faltering in order to facilitate ameliorative action (usually food supplementation or nutrition education) to prevent malnutrition. It also aims to facilitate the active participation of mothers in ensuring their child's continual good growth. The history of growth monitoring and its use in the South African context is discussed. The underlying rationale and component processes needed to implement it effectively are identified in a review of process evaluation studies of growth monitoring. Thornhill is an impoverished African rural area in the Ciskei in which malnutrition is a serious health problem and growth monitoring has been systematically implemented. However, although the health service had a demonstrated capacity for successful health interventions it had been unable to improve nutritional status. Background information and previous research in the area is presented. The study aimed to explore why growth monitoring had failed to improve nutritional status in Thornhill by investigating the way in which the component objectives of growth monitoring in terms of making growth visible, facilitating nutrition intervention and facilitating mothers' participation in their children's care were perceived by mothers and health workers.